U.S. Payments Forum Membership Application



U.S. Payments Forum Membership ApplicationInstructions for completing this form: This form can be completed on your computer by clicking on thehighlighted areas to enter text or checking the appropriate box. Once completed, please send the form by email as an attachment to rvanderhoof@ or fax to the U.S. Payments Forum at (1)-609-897-anization Name: FORMTEXT ?????Completing this application form serves as a letter of intent by the organization listed above to join the U.S. Payments Forum, a cross-industry body that addresses a variety of payments technologies that protect the security of, and enhance opportunities for payment transactions within the U.S. The U.S. Payments Forum bylaws define seven membership categories. Select the appropriate membership level you intend to join. Please carefully review the benefits and any restrictions associated with each level.Please Check Appropriate Box Membership LevelAnnual Membership FeeAnnual Membership Fee – Dual Membership(current Secure Technology Alliance members receive 20% discount) FORMCHECKBOX Global Payments Network FORMCHECKBOX US $25,000 Not applicable FORMCHECKBOX Principal PLUS Member* FORMCHECKBOX US $18,000 Not applicable FORMCHECKBOX Principal Member FORMCHECKBOX US $12,000 FORMCHECKBOX US $9,600 FORMCHECKBOX General Member FORMCHECKBOX US $5,000 FORMCHECKBOX US $4,000 FORMCHECKBOX Industry Association Member FORMCHECKBOX US $1,750 FORMCHECKBOX US $1,400 FORMCHECKBOX Government Member FORMCHECKBOX US $1,750 FORMCHECKBOX US $1,400 FORMCHECKBOX Associate Member FORMCHECKBOX US $1,200 FORMCHECKBOX US $960* This level of membership in the Forum includes privileges in the Secure Technology Alliance FORMCHECKBOX I acknowledge that I have read the U.S. Payments Forum bylaws, meet the qualifications for the membership level selected, and agree to the terms and conditions of the U.S. Payments Forum.U.S. Payments Forum membership runs for one year, beginning with the first day of the month that the application is received. This membership expires one year after the start date of this membership. The applying member intends to join the U.S. Payments Forum at the membership level indicated above and agrees to the payment of the annual membership fee. Payment terms are (30) days from the date of signing this application.Method of Payment: FORMCHECKBOX Check FORMCHECKBOX Visa FORMCHECKBOX MasterCard FORMCHECKBOX American Express FORMCHECKBOX Discover Make checks payable to “The Secure Technology Alliance,” and mail to: Secure Technology Alliance, 191 Clarksville Road, Princeton Junction, NJ 08550. (the U.S. Payments Forum shares a banking and membership administrator relationship with the Secure Technology Alliance) FORMCHECKBOX Wire Transfer I request wire transfer instructions be sent to new member contact Name on Card FORMTEXT ?????Card Number FORMTEXT ?????Billing Address:(Including street, city, state or province) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Postal Code: FORMTEXT ?????Country: FORMTEXT ?????Expiration Date FORMTEXT ?????Card Security Code: FORMTEXT ?????Name authorizing this application FORMTEXT ?????Date: FORMTEXT ?????Please complete the following information about your organization:Organization Name: FORMTEXT ?????Web URL: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Postal Code: FORMTEXT ?????Country: FORMTEXT ?????Primary Member Point of Contact (for official letters and renewal notices and/or payments)Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Organization Type(e.g., issuer, processor, merchant, acquirer, global/regional payment network, industry supplier, consultant) FORMTEXT ?????Primary Service Offered (e.g., cards, devices, terminals, card issuance, services, payments applications) FORMTEXT ?????Provide short description of company: FORMTEXT ?????Permission to include company name on membership lists for general marketing purposes FORMCHECKBOX Yes FORMCHECKBOX NoPermission to provide link from U.S. Payments Forum site to your organization's website: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide exact URL to link to your website: FORMTEXT ?????Please list the referring U.S. Payments Forum member that led you to join, if applicable:Name: FORMTEXT ?????Company: FORMTEXT ?????Please list the contact (if other than the Primary Contact) representing your company in U.S. Payments Forum programs, events, and other member activities:Name FORMTEXT ?????Title: FORMTEXT ?????Company: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Postal Code: FORMTEXT ?????Country: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Other contacts, such as 3rd party PR firm, to receive email sent by the Forum to its members, including the weekly industry news, Forum news and announcements, Forum Monthly Member Bulletin, Forum Quarterly Newsletter, and other communications:Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Email: FORMTEXT ?????Please email this form as an attachment to rvanderhoof@ or fax to the U.S. Payments Forum at (1) 609-897-0262. Thank you for your interest! ................
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